Health Care Reform Health Care Reform Update Update WCOMO February 15, 2013 Mary Wood, Section Manager, HCA Eligibility and Service Delivery
Jan 11, 2016
Health Care Reform UpdateHealth Care Reform Update
WCOMOFebruary 15, 2013
Mary Wood, Section Manager, HCA Eligibility and Service Delivery
Topics for Today
Health Care Reform Overview Health Benefit Exchange Web Portal Consumer Assistance Post-Eligibility Case Reviews Benefit Package for Adults Health Care Reform Resources
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Health Care Reform Overview
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2014 ACA Continuum of“Insurance Affordability Programs”
* Federal Basic Health Plan Option for individuals with incomes between 138% and 200% of the FPL will not be available in 2014.
Optimize opportunities to streamline administrative processes
Leverage new federal financing opportunities to ensure the Medicaid expansion is sustainable
Maximize use of technology to create consumer-friendly application/enrollment/renewal experience
Maximize continuity of coverage & care as individuals move between subsidized coverage options
Reform the Washington Way --- comply with, or seek waiver from, specific ACA requirements related to coverage and eligibility, as needs are identified
Health Care Reform Goals
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2014 Medicaid Coverage
* The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard
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Option to expand Medicaid to 138% of the FPL for adults under age 65 not receiving Medicare* - based on Modified Adjusted Gross Income (MAGI)
– MAGI methodology defines how income is counted, and how household composition and family size are determined
– MAGI will determine eligibility for children, pregnant women, parents and all adults in the new adult category
– Non-MAGI (classic) Medicaid eligibility standards will still apply to aged, blind, disabled, SSI, & foster children – ACA doesn’t impact these groups
Washington’s new adult group will include:– Childless adults with incomes below 138% of the FPL– Parents with incomes between ~40% and 138% of the FPL
Federal Poverty Level Annual Income: Individual
Annual Income Level:Family of 3
100% $11,170 $19,090
133% $14,856 $25,390
138% $15,415 $26,344
200% $22,340 $38,180
300% $33,510 $57,270
400% $44,680 $76,360
Federal Poverty Levels and Annual Income (2012)
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Newly eligible parents and childless adults are:– under 65 years old– not pregnant– not entitled to Medicare– not in an existing Medicaid category (e.g. children, pregnant women,
aged, blind and disabled)
Enhanced federal funding for costs of newly eligible adults:
Enhanced Federal Funding for New Adult Group
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2014 2015 2016 2017 2018 2019 2020 +
State Share 0% 0% 0% 5% 6% 7% 10%
Federal Share 100% 100% 100% 95% 94% 93% 90%
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2012 2013 2014
Oct 1 2013: Go LiveOpen enrollment begins. Medicaid applications & renewals accepted
Jan 1 2014: Coverage BeginsMedicaid coverage for newly eligible adults begins
Aug 2013: Complete System Performance and Operational Readiness Testing
Nov-Dec 2012:→Fiscal modeling→Official Caseload Forecast Council maintenance projections→Governor’s 2013-15 budget
Jan-May 2013: → Legislative Session→ WAC revisions→ Ongoing operational
stakeholdering→ Initiate marketing & outreach
campaign for Medicaid.→ Complete System Development
and Unit Testing by Feb 2013.→ Primary care provider rate
increases (Jan 2013-Dec 2014).
Dec 31, 2014: Conversion to MAGI Medicaid complete for all eligible enrollees
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Jun-Nov 2012: System Detail Design for MAGI Medicaid eligibility/enrollment
Aug-Dec 2012: Medicaid operational stakeholdering→Application Forms→Renewals Process→Quality Assurance→Client Letters
Timeline: Much Work to be Done!Sep 2013: CMS Systems Certification
May 2012 – Apr 2013: → Benchmark Benefit Design→ Optional Programs
Transition
Jan-Dec 2014: Phased implementation of further systems features (tbd)
Health Benefit Exchange Web Portal
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The Exchange: One-Stop Shopping for CoverageThink: Amazon.com or Expedia... a simple way to shop for health insurance
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Washington Healthplanfinder
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Washington Healthplanfinder
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Washington Healthplanfinder
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Coordinated Entry SystemsNEW Revised Interface
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Consumer Assistance
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Consumer Assistance
To reach uninsured Washington residents, the state will rely on:
Navigators, Agents and Brokers: will provide help to consumers and small businesses with enrolling into coverage on the Exchange; provide advice to consumers about their enrollment options and premium tax credits; and make referrals of complex cases to Consumer Assistance Programs
Call Center: Toll-Free Hotline operated by the Exchange to provide insurance application assistance
Community-Based Organizations: Continued partnership with existing community-based network
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Community-Based OrganizationsCBOs can assist with outreach to Washington State residents such as:
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New applications:– Assist individuals in applying for health care coverage through the new health
benefit exchange web portal. Target Newly Eligible Adults age 19-64 with income up to 138% FPL.
Transitions from other coverage:– Support current Basic Health members as they use the new
Washingtonhealthplanfinder portal (Oct-Dec 2013) to transition to coverage for January 2014
– Follow up with Medical Care Services and ADATSA clients regarding their automatic conversion to coverage beginning January 2014
Renewals of Medicaid coverage:– Encourage/assist current Medicaid recipients (children, parents, pregnant
women) who must renew coverage using the Washingtonhealthplanfinder portal during 2014 (and beyond)
Post-Eligibility Case Reviews
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Post-Eligibility Case Reviews
Post reviews will target cases where:– Self-attested income cannot be electronically
verified– Electronic data matches not reasonably
compatible
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Draft – WA Apple HealthReasonable Compatibility Model
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Post-Eligibility Activities
Review additional electronic interfaces (e.g. TALX, ESD)
Contact client or employer to obtain additional information
If necessary – send a request for information letterClient remains eligible during post-eligibility review
When eligibility cannot be electronically affirmed – HCA eligibility staff will take the follow steps to resolve the inconsistencies:
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Post-Eligibility Activities
Eligibility confirmed – no change Eligibility not confirmed – client is:
– Moved to appropriate MAGI program; or– Redetermined for Classic Medicaid; or– Referred to Exchange web portal for APTC determination
Once the post-eligibility review is completed staff will take the following action:
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Benefit Package for Adults
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Benefits for New Medicaid Adult Group Called Alternative Benefit Plan (aka Medicaid
Benchmark)
Benefits for new adults must:– Cover all 10 essential health benefits (EHBs) as defined for
Medicaid (may be different from Health Benefits Exchange)– Meet mental health parity (currently applies to private health
plans and Medicaid managed care but not fee-for-service)– Cover non-emergency medical transportation – Cover Early Periodic Screening, Diagnosis and Treatment
(EPSDT)– Address CMS January proposed regulations and guidance
Benefits for new adults may:– Align with existing Medicaid benefit package– Differ for different eligibility groups
Essential Health Benefits1. Ambulatory services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use
disorder services, including behavioral health treatment
6. Prescription drugs7. Rehabilitative and habilitative
services and devices8. Laboratory services9. Preventive and wellness services
and chronic disease management10. Pediatric services, including oral
and vision care
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Problem - Multiple ABPs for AdultsConsumersPotential for fewer benefits to be covered by current Medicaid standard creates equity issue and confusion over care covered when circumstances change Medicaid enrollee’s income
ProvidersService delivery and payment confusing if coverage for Medicaid adults differs between Medicaid standard and the ABP
Health PlansTracking and communicating benefit changes to enrollees (and their providers) increased and complex; provider payments confused when adult status within Medicaid changes; rate development more difficult
State/Federal GovernmentsSystems interfaces and administration complicated when adult status within Medicaid changes (e.g., increased tracking and monitoring; challenging communication to beneficiaries, providers and health plans; complex payments and reconciliation)
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Medicaid expansion offers new opportunities to reconsider enforceable, limited, cost sharing for the new adult group to:Promote use of evidence-based cost-effective treatment while reducing low-value and medically unnecessary careAvoid discouraging or creating barriers to essential and appropriate careAvoid cost-sharing cliff between Exchange and Medicaid coverage Maintain consistency with historical policy direction for low-income adults to contribute to their health careFacilitate provider collection of required co-paymentsMaximize use of consumer-friendly, administratively simple processes.
Draft Cost-Sharing Principles for WA
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Limited, enforceable cost sharing for newly eligible adults between 100-138% of the FPL as a bridge to Qualified Health Plan coverage in the Exchange
Preliminary 2014 implementation design– No premiums– No cost-sharing in Medicaid fee for service– Cost sharing through managed care plans only– Out-of-pocket costs tracked by managed care plans
Align point of service cost sharing for Medicaid adults with Exchange adults at same income level
“Strawman” proposals available for review and comment at: http://www.hca.wa.gov/me/documents/alternative_benefit_plan_strawman020713.pdf http://www.hca.wa.gov/me/documents/cost_sharing_strawman020713.pdf
Cost-Sharing “Strawman” for Discussion
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Health Care Reform Resources
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More Information Web-sites: http://www.hca.wa.gov/
− For information about the Medicaid expansion: http://www.hca.wa.gov/hcr/me
− For information about the Health Benefit Exchange: http://wahbexchange.org/− To contact the HCA concerning the Medicaid expansion:
Webinars and presentations around the state− See upcoming schedule and past events at: http://www.hca.wa.gov/hcr/me/stakeholdering.html
Listserv notification− Subscribe at: http://listserv.wa.gov/cgi-bin/wa?SUBED1=HCA-STAKEHOLDERS&A=1
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